Pediatric Tuberculosis: Pearls, Pitfalls and Progress. Amina Ahmed, MD Levine Children s Hospital June 25, 2013

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1 Pediatric Tuberculosis: Pearls, Pitfalls and Progress Amina Ahmed, MD Levine Children s Hospital June 25, 2013

2 Disclosures I have no relationships with commercial interests related to this presentation I will be discussing off-label use therapeutic agents

3 Pediatric TB: Overview Epidemiology Natural history Clinical presentation Evaluation Screening, contact investigation Latent TB infection (LTBI) Evaluation for disease Evaluation of an infant born to a mother with TB Treatment

4 Pediatric Tuberculosis: Why Children Are Not Little Adults Natural history Increased risk of progression to disease Paucibacillary disease Clinical presentation Nonspecific symptoms Diagnosis of LTBI/TB Immune system- TST and IGRA less reliable Sputum collection difficult Paucibacillary disease- microbiological confirmation difficult Treatment of LTBI/TB Recommendations based on adult treatment trials

5 Tuberculosis in the United States ~ 11,000 cases/year 5% of cases in children < 15 years of age ~ million cases of LTBI

6 Demographic Characteristics of US- and Foreign- Born Persons with TB: United States, Am J Public Health 2010; 100:

7 Am J Public Health 2010; 100:

8 Pearls and Pitfalls : Epidemiology TB or LTBI in a child is a sentinel event representing ongoing transmission of TB within a community Children at risk include the foreign-born and those with foreign-born guardians

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10 Natural History of Pediatric TB Exposure Infection Disease Disease usually a rapidly evolving complication of the primary infection as opposed to reactivation type disease in adults Incubation period for disease may be 6-8 weeks, before delayed type hypersensitivity (DTH) develops Timely identification of children exposed to TB is critical in preventing disease

11 Risk of Disease Following Primary Infection Age Disseminated TB/ TB meningitis Pulmonary TB No Disease < 1 year 10-20% 30-40% 50% 1-2 years 2-5 % 10-20% 75-80% 2-5 years 0-5% 5% 95% 5-10 years < 0-5% 2% 98% > 10 years < 0-5% 10-20% 80-90% Lancet Infect Dis 2008; 8:

12 Pearls: Pediatric versus Adult TB Rate of progression to disease is faster Disease may be a rapid consequence of infection Risk of progression to disease is higher Adults: 5-15% Children 1-5 y: 25-30% Infants <1 y: 40% Severe disease is more common Adults: 15% extrapulmonary Children: 25% extrapulmonary

13 Clinical Presentation of Pediatric TB Pulmonary TB Typically asymptomatic Most cases identified by contact investigation Extrapulmonary Lymphatic, meningitis, miliary, osteomyelitis Typically symptomatic

14 Presentation of Childhood Tuberculosis Cases Cases No. cases Median age 24 mo 8 mo Initial visit Symptomatic 48 (44%) 37 (79%) Asymptomatic 62 (56%) 10 (21%) Asymptomatic-Referral Contact investigation 55 (89%) 9 (90%) Screening 7 (11%) 1 (10%) Pediatrics 1989; 84:28-35; Pediatrics 1994; 94:1-7

15 Pulmonary TB in Children The majority of children have no or few signs or symptoms of disease Identified through contact investigation Infants / adolescents more likely symptomatic Fever, cough, weight loss or FTT Physical findings are limited Cough, wheezing Hemoptysis, night sweats in adolescents

16 Extrapulmonary TB: Lymphadenitis Localized adenopathy Supraclavicular, cervical, submandibular Systemic symptoms minimal Generalized adenopathy Cervical, supraclavicular Systemic symptoms present Abnormal CXR only in 30-70% cases

17 Extrapulmonary TB : Meningitis Occurs in 2-5% of untreated children Highest attack rate in those < 4 years Occurs within 8 weeks of infection Progression of disease Stage I- nonspecific symptoms, fever Stage II- vomiting, CN palsies, seizures Stage III- coma

18 TB of the Central Nervous System Cerebrospinal fluid Mild pleocytosis ( WBC/mm 3 ) Glucose low / protein elevated (up to 400 mg/dl) MTB isolation in 20-50% of cases Radiography (CT, MRI) Basilar meningitis, hydrocephalus, infarcts, tuberculomas

19 Pearls and Pitfalls: Clinical Presentation Pulmonary TB Nonspecific signs and symptoms- high index of suspicion required to prevent progression of disease Extrapulmonary TB CXR not always abnormal in EP TB TB meningitis/tuberculoma may present with nonspecific symptoms in early disease Aseptic meningitis with hydrocephalus or basilar meningitis should be assumed to be TB until proven otherwise

20 Evaluation of Children for TB Screening as part of general pediatric care Exposure Evaluation of a child who is a contact to an adult with potentially contagious TB Evaluate for LTBI and TB Infection -evaluation of child diagnosed with reactive TST Evaluate for LTBI and TB Disease (symptomatic or asymptomatic) Confirm TB Evaluate for extent of disease and extrapulmonary TB

21 Screening : Targeted TB Skin Testing Immediate TST Contacts of confirmed or suspected TB Radiographic or clinical suggestion of TB Travel to/ immigration from endemic countries (including international adoptees) Annual TST HIV-infected Incarcerated adolescents Report of Committee on Infect Dis, 2009

22 Diagnostic Tools for LTBI Tuberculin skin test (TST) Purified protein derivative (PPD) Reactivity is the hallmark of primary infection DTH may take 2-12 weeks Sensitivity and specificity 90% Negative TST does not definitively exclude TB IFN assays (IGRAs) Blood tests measuring lymphocyte IFN release

23 Interpretation of Reactive TST 5 mm Contact of infectious case Suspected disease Immunosuppressed 10 mm Age 4 years Medical risk factors Birth/travel to high prevalence area Contact with high-risk adult 15 mm Age > 4 years and no risk factors Report of Committee on Infect Dis, 2012

24 What about BCG? Administered routinely in most areas of the world < 50% of infants given BCG at birth have a reactive TST at 9-12 months of age 80-90% have nonreactive test by 5 years Interpretation of reactivity should be independent of BCG history, as with adults

25 Pearls and Pitfalls: TST Confounders False Positives Nontuberculous mycobacteria Receipt of the BCG vaccine Inexperienced reader False Negatives Immunodeficiency Young age Receipt of live viral vaccines Overwhelming disease Inexperienced reader PPV depends on prevalence 90% prevalence, PPV is 99% 1% prevalence, PPV is 8%

26 Progress (?) in Diagnosis of LTBI : Interferon Release Assays (IGRAs) Release of IFN from white blood cells in response to stimulation by MTB antigens Proteins coded by a unique region of MTB ESAT-6, CFP-10, TB7.7 No cross reactivity with BCG or most NTM Two assays Quantiferon Gold In Tube (QFT IT) ELISPOT, T-SPOT

27 TST versus IGRAs Crude mixture of proteins Highly specific antigens Lancet 2000; 356:

28 TST versus IGRAs TST IGRAs Cheap Not so much Requires no laboratory support Requires equipped laboratory Requires 2 visits Completed in 1 visit Reliability variable Reliable Results delayed h Rapid results Cross reactivity with NTM Limited cross reactivity with NTM Cross reactivity with BCG No cross reactivity with BCG Cannot distinguish between LTBI and TB Cannot distinguish between LTBI and TB

29 Progress: Should IGRAs Replace TSTs? Multiple studies comparing IGRA to TST Interpretation of results confounded by lack of gold standard and heterogenous study designs Confounders Young age- lower mitogen and antigen response May be unreliable in young children Indeterminate results Ann Intern Med 2008; 149:

30 Performance of IGRAs: Estimates Adult and Pediatric Studies Sensitivity ( %) Specificity (%) TST 89 (63-100) 85 (22-100) QFT 83 (56-93) 99 (99-100) T-Spot 90 (50-100) 88 (85-100) Pediatric Studies TST 80 (70-90) 85 (63-100) QFT 83 (75-92) 91 (78-100) T-Spot 84 (63-100) 94 (87-100) Ann Intern Med 2008; 149: IJTLD 2011; 15: MMWR 2010; 59 (RR-5): 1-25

31 How do we use IGRAs in children? Not routinely recommended to replace TST Consider for older children, children who are unlikely to return for a TST reading, and as part of dual testing for high risk situations Discourage use for: Diagnosis or exclusion of disease Young children (< 5 years of age) More indeterminate results Less agreement between TST and IGRA Higher risk for development of disease Immunocompromised

32 Out of Africa 3 year old adopted from Ethiopia BCG scar present TST placed- 15 mm Mother has read about a new blood test that can tell BCG reaction from true LTBI What do you do?

33 Learning is Contagious 14 year old exposed to a teacher with tuberculosis TST reactive CXR normal The mother does not believe the TST Mother wants TST repeated Should you offer Quantiferon Gold IT? Mother wants them bothshe ll take the best 2 out of 3!

34 Pearls, Pitfalls and Progress: Screening for TB Screening for TB should be targeted towards those at risk for LTBI or progression to TB Immigrants (adoptees, refugees) International travel Beware of limitations of TSTs and IGRAs Sequential or dual testing in limited circumstances Consider IGRAs in older children

35 Evaluation of Children for TB Screening as part of general pediatric care Exposure Evaluation of a child who is a contact to an adult with potentially contagious TB Evaluate for LTBI and TB Infection- evaluation of child diagnosed with reactive TST Evaluate for LTBI and TB Disease (symptomatic or asymptomatic) Confirm TB Evaluate for extent of disease and extrapulmonary TB

36 Contact Investigation CI of children exposed to confirmed or suspected TB is a critical role of the HD History, physical examination TST CXR (PA and lateral films) To evaluate for disease if TST reactive Before initiating INH if TST nonreactive

37 Contact Investigation in Adults and Children 5 Years of Age TST nonreactive Repeat TST in 8 weeks TST reactive CXR normal Treatment for LTBI CXR abnormal- evaluate further for disease Treatment for TB

38 Contact Investigation in Children < 5 Years of Age Initial TST nonreactive CXR normal INH for 8 weeks Repeat TST nonreactive stop INH Repeat TST 5 mm repeat CXR If CXR normal, INH for 9 mo For infants < 6 months, consider INH for 9 mo CXR abnormal Consult physician Initial TST 5 mm CXR normal INH for 9 mo CXR abnormal Consult physician NC TB Manual:

39 Tia with TB 4 month old exposed to an aunt with suspected pulmonary TB PE normal TST nonreactive How do you proceed? Repeat TST in 8 weeks is reactive- now what?

40 Latent Tuberculosis Infection Hallmark of LTBI is reactive TST in the absence of clinical or radiographic evidence of disease Identified either through Contact investigation Targeted tuberculin skin testing (risk-based) Further evaluation for disease Physical exam CXR

41 We all have positive TSTs It s cultural 10 year old born in India; BCG vaccinated How do you proceed with evaluation? Returned home last year for 2 months Screened has reactive TST

42 Imported TB 9 month old adopted from Guatemala BCG vaccinated TST reactive at 15 mm Asymptomatic except for a cold with cough Now what?

43 Imported TB Patient admitted GA, BAL Induced sputum HIV testing, LP Treatment with IRPE started MTB isolated Fully susceptible IRP for 2 months, IR continued for 4 months Picture reprinted with permission from parents.

44 Pearls and Pitfalls: Exposure and LTBI Preventable cases of childhood TB occur when timely contact investigation is not performed For young children, window prophylaxis indicated Sometimes window prophylaxis fails Evaluate any child with a reactive TST for disease The placement and reading of TSTs is a lost art Consider repeating or IGRA if false positive likely

45 Evaluation of Children for TB Screening as part of general pediatric care Exposure Evaluation of a child who is a contact to an adult with potentially contagious TB Evaluate for LTBI and TB Infection- evaluation of child diagnosed with reactive TST Evaluate for LTBI and TB Disease (symptomatic or asymptomatic) Confirm TB Evaluate for extent of disease and extrapulmonary TB

46 Suspected Tuberculosis Pulmonary Pneumonia unresponsive to antibacterials Hilar adenopathy on CXR Cavitary pneumonia (adolescents) Pneumonia or hilar adenopathy after exposure Extrapulmonary Lymphadenitis (subacute, granulomatous) Aseptic meningitis Miliary pattern on CXR

47 Diagnostic Tools : Disease TST Radiography CXR- PA and lateral CT (chest), MRI (brain) Mycobacteriology Gastric aspirate (GA) Bronchoalveolar lavage (BAL) Induced sputum, tissue CSF MTB PCR Source identification

48 Radiographic Findings in Pediatric TB Hilar adenopathy is the most common abnormality PA and lateral films recommended Segmental collapse, hyperinflation Lobar infiltrate noted occasionally Cavitary lesions uncommon

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53 Mycobacteriology Bacteriologic confirmation is difficult in children Sputum difficult to obtain in children < 10 y GA collection requires hospitalization Tubercle bacilli sparse Isolation of MTB important if: Source case unknown or more than one source Isolate not available Resistance suspected

54 Specimens for Mycobacteriology Pulmonary GA is specimen of choice Isolation of MTB in 50-70% specimens- can be higher! Bronchoalveolar lavage (BAL)- yield lower but helpful Induced sputum Extrapulmonary Tissue- yield > 50% CSF- yield < 50% AFB smears positive in < 10% of all specimens Negative smear or negative culture does not exclude TB in children

55 Collection of Gastric Aspirate Hospitalize patient; notify laboratory 3 consecutive early morning specimens after overnight fasts NG tube placed the night before collection Gastric contents aspirated Lavage with ml sterile water if no aspirate Timely transport to the lab for immediate neutralization NC TB Manual:

56 Management of Pulmonary Disease Identified by Contact Investigation A child contact of an adult with TB with an abnormal CXR is presumed to have TB until proven otherwise An abnormal CXR is not always TB - review with a pediatric radiologist if possible Attempt bacteriologic confirmation if CXR suggestive of TB and isolate not available or resistance suspected

57 If at first you don t succeed 19 month old with a mother hospitalized with suspected TB TST reactive CXR sent for review Physical examination normal per PCP How would you manage this patient? Do we need to obtain gastric aspirates? If she has pulmonary TB, what further evaluation is recommended?

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59 Further Evaluation of TB Mycobacteriological confirmation not needed Source case known and isolate available Evaluate for dissemination of disease Physical examination, LFTs, HIV test LP recommended in children 2 years of age even if asymptomatic

60 Why the Lumbar Puncture? Meningitis is an early complication of infection May occur before DTH develops Children 4 y of age primarily affected Insidious process occurring over 3-6 weeks Management of disease affected by meningitis Duration of therapy prolonged Adjunctive use of corticosteroids Recommended in children 2 years of age with TB disease, even in the absence of neurological symptoms

61 Back to the patient... Asymptomatic except perhaps irritable To ED for LP (and repeat CXR) CXR done but not checked LP required sedation but patient ate Tootsie Pop Return to ED the next day for LP No staff for LP- admitted for LP LP done- CSF reported normal; patient discharged WBC 30, RBC 113,000, glucose 52, protein 466

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63 Management of Clinically Suspected TB Bacteriologic confirmation if source case unknown GA, BAL, sputum Yield from 3 GA is higher than from BAL Source case investigation Identification of adult source of infection Critical to diagnostic evaluation Likelihood of identifying source case (and isolating MTB) is higher than isolating MTB from patient

64 It s a Family Affair 5 month old Hispanic female evaluated in ED with a cough CXR - hilar adenopathy Admitted for evaluation How would you manage this patient? TST? Gastric aspirates? LP? How would you treat this patient?

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66 Diagnosis : Source Identification Identification of (adult) source of infection Critical to diagnostic evaluation of the child with suspected TB disease Source case is likely an adult from whom MTB more likely to be isolated

67 Back to the patient GA X 3, induced sputum X 1 CSF: 0 WBC, O RBC, protein 30, glucose 55 4 drug regimen initiated Source case hunt 4 siblings with LTBI Parents with LTBI Isolation of MTB from GA specimen- matched source s

68 Pearls and Pitfalls: Symptomatic Disease Children get TB from adults around them Rapid progression to disease The younger the child, the higher the risk Most children with pulmonary TB are asymptomatic Evaluation of suspected pulmonary TB Bacterial isolation necessary if unknown source Bacterial isolation not necessary if source is known Source case identification is helpful for diagnosis LP is recommended in young children (< 2 y) with pulmonary TB

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70 Pregnancy and Tuberculosis Rates of LTBI mimic those of the general population Pregnant and postpartum women may have a higher risk of TB disease Controversies in treatment of LTBI Risk to fetus and newborn infant Congenital TB, perinatal TB

71 Congenital Tuberculosis Rare- true incidence unknown Most cases reported in foreign-born women living in nonendemic areas May be due to infertility due to genital TB Pathogenesis Hematogenous spread from placenta to umbilical vein In utero ingestion/aspiration of infected amniotic fluid Intrapartum ingestion of amniotic fluid or infected genital secretions

72 Reviews of Cases of Congenital Tuberculosis Cases Reported in the English-Language Literature in the Era of Chemotherapy Reference Hageman et al, 1980 Cantwell et al, 1994 Abughali et al, 1994 Years Cases Reported No. of Cases Age at Clinical Presentation (d) No. of Infants With Reactive TST Common Symptoms NR 2 of 14 Respiratory distress Fever Hepatomegaly Median 24 (range 1 to 84) 0 of 9 Hepatosplenomegaly Respiratory distress Fever NR 1 of 19? Respiratory distress Hepatomegaly Fever Mortality (%) (With Treatment) 46 (12) 38 (22) 45 (14) Laartz et al, Mean 17.4 (range 1 to 60) 1 of 4 Respiratory distress Hepatomegaly Fever 20 Avery s Dis of the Newborn, 9 th Ed.

73 Congenital Tuberculosis Presentation typically at 2-4 weeks of age Nonspecific- mimics bacterial sepsis Fever, respiratory distress Hepatomegaly. OM/drainage, rash CXR may be abnormal Criteria for diagnosis Evidence of TB in the first week of age Infection of the placenta or genital tract Exclusion of postnatal transmission

74 Clinical Signs of Congenital Tuberculosis in 58 Infants Sign No. of Patients % of Patients Respiratory distress Hepatomegaly with or without splenomegaly Fever Lymphadenopathy Poor feeding Lethargy, irritability Abdominal distention Failure to thrive 9 15 Ear discharge 9 15 Rash 5 9 Abnormal fundoscopic findings 4 7 Jaundice 4 7 Seizure 3 5 Bloody diarrhea 3 5 Ascites 3 5 Avery s Dis of the Newborn, 9 th Ed.

75 Avery s Dis of the Newborn, 9 th Ed.

76 Evaluation for Congenital TB TST Unreliable but helpful to have baseline CXR (PA, lateral) Mycobacterial confirmation GAs, tracheal secretions, CSF, otorrhea, tissue Yield higher than for older children Examination of mother PE including genital/uterine examination Placenta biopsy, culture

77 Management of the Newborn Whose Mother has LTBI Mother has reactive TST and normal CXR If mother is asymptomatic, no separation Mother should be treated for LTBI Newborn needs no further evaluation Household members should be evaluated for TB infection or disease

78 Management of the Newborn whose Mother has Suspected TB Mother has clinical signs/symptoms or abnormal CXR Evaluation of mother (e.g. sputum, HIV serology) Evaluate infant for congenital TB If excluded, begin INH Separation of mother and infant until evaluation complete and, if TB suspected, until mother receiving appropriate therapy Once INH started for infant, separation no longer necessary unless mother has DR TB Isolation of newborn only if intubated or undergoing procedures involving airway

79 Management of the Newborn whose Mother has Suspected TB Mother has reactive TST and abnormal findings on CXR but no evidence of TB Mother should receive LTBI treatment Separation not necessary Household should be investigated for TB

80 Management of Infants Born to Mothers with a Positive TST Mother: Tuberculin Skin Test Positive Asymptomatic Infant Symptomatic Infant Maternal chest x-ray normal; no active disease No Maternal chest x-ray abnormal Maternal evaluation consistent with TB? Yes Mother with clinical or radiographic evidence of contagious TB TST, chest x-ray Lumbar puncture AFB culture: gastric aspirate, endotracheal aspirate, CSF Head CT scan or MRI. Multi-drug treatment (see text) Airborne isolation Consult infectious disease specialist Maternal treatment for TB 2 wks, sputum AFB negative, and strain not multi-drug resistant Maternal treatment none or 2 wks, sputum AFB positive, or strain is multi-drug resistant No infant evaluation or therapy required Separate infant from mother until she is non-contagious (treatment 2 wks) or infant on appropriate TB drug(s). Evaluate infant for congenital tuberculosis TST; chest x-ray AFB culture: gastric aspirate, endotracheal aspirate Consider lumbar puncture and AFB culture of CSF Consult infectious disease specialist; notify local health department Evaluation consistent with congenital tuberculosis? INH for 3-4 months If maternal TB strain is multi-drug resistant, consider BCG vaccine Follow-up TST at 3-4 months: Negative test: stop INH. Positive test: Reassess for TB as in symptomatic infant. If no other evidence of TB, INH for 9 months. No Yes Lumbar puncture if not previously done Consider head CT or MRI Multi-drug treatment (see text) Avery s Dis of the Newborn, 9 th Ed.

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82 Treatment of LTBI and TB LTBI TB Self-administered For children < 5 years of age, directly observed preventive therapy (DOPT) twice weekly Directly observed therapy (DOT)

83 Progress: Treatment of LTBI Standard INH for 9 months (daily or DOPT twice weekly) 90% effective in reducing risk of TB in children Alternatives Rifampin for 6 months INH and rifapentine weekly by DOT for 12 weeks Option for children 12 years of age Alternatives to come.. INH and rifapentine for children 2 years of age Rifampin for 4 months INH and rifampin daily for 3 months MMWR 2011; 60 (48):

84 Progress: Adherence Pediatr Infect Dis J 2012;31:193

85 Progress: PREVENT TB Trial 3 months of INH and rifapentine administered weekly by DOPT compared with 9 months of daily INH TB in 7/3986 subjects in the combination-therapy group (0.19%) and in 15/3745 subjects in the INH group (0.43%) Rates of completion 82% in the combination group vs 69% in the INH group Rates of discontinuation and hepatotoxicity Significantly lower in the combination group N Engl J Med 2011;365:

86 Progress: PREVENT TB Pediatric Data Variable INH/RPT INH p-value N Completion 88% 80% Permanent discontinuation due to adverse event 1.3% 0.8% 0.65 Drug-related hepatotoxicity children 2-17 yrs old 7 cases of possible hypersensitivity in INH/RPT group, 0 in INH group Villarino et al. IDSA Abstract, 2012

87 Treatment of Pulmonary TB Drug-susceptible disease Initial INH, RIF, PZA +/- EMB daily for 2 weeks, then daily or 2x/week for 6 weeks Continuation INH and RIF daily or 2x/week for 4 months Children or adolescents with adult-type disease or children in whom drug-resistance suspected Initial : four drugs (INH,RIF,PZA and EMB) 2009 Committee on Infectious Disease, American Academy of Pediatrics (Red Book)

88 Treatment of Extrapulmonary TB As for pulmonary TB except for meningitis, miliary and bone/joint disease Meningitis Initial : 4 drugs (INH,RIF,PZA, and EMB) Continuation: INH and RIF for 7-10 months Miliary disease and bone/joint disease Total of 9-12 months of therapy 2009 Committee on Infectious Disease, American Academy of Pediatrics (Red Book)

89 Administration of Therapy Children with low bacillary load and low likelihood of resistance Patient may not have pathogen isolated confirm susceptibility from source Daily therapy in first 2 weeks is 5 or 7 days/week Continuation phase daily or 2x/week

90 Monitoring of Therapy : Adherence Children often receive little medication in the first few weeks due to vomiting and difficulty with administration Convey to family that incomplete compliance to be expected early in treatment Health department ultimately responsible for ensuring that appropriate treatment is delivered

91 Monitoring of Therapy: Adverse Effects Rates of adverse effects are low Monthly clinical monitoring for signs/symptoms Monitoring of transaminases not recommended except for CNS or disseminated TB Underlying liver disease Symptoms of liver dysfunction EMB- visual acuity and color vision should be monitored

92 Monitoring of Therapy: Outcome Clinical Symptoms typically mild at initiation of therapy Microbiological efficacy often not possible in children Radiological resolution Hilar adenopathy may not resolve for 1-3 years CXR should be repeated 1-2 months into regimen; if improving, repeat at the end of therapy Normal CXR not necessary to stop therapy

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